The vulnerability of migrants living in large urban areas to COVID-19: Exacerbators and mitigators

Abstract Background Even though large urban areas have been researched in the context of COVID-19, evidence on how COVID-19 impacted migrants -a particularly vulnerable group- in these settings is still limited. Objective: To explore exacerbating and mitigating factors of large urban areas on migrants’ vulnerabilities during the COVID-19 pandemic. Methods We conducted a systematic review of peer-reviewed literature published between 2020-2022 and focused on migrants (foreign-born individuals who have not been naturalized in the host country, regardless of immigration status) in urban areas with a population >500.000. After screening 880 studies, 29 studies were included and categorized within the following thematic framework: 1) Underlying structural inequities, 2) governance and economic structure, 3) urban design, and 4) engagement of civil society organizations (CSO). Results Exacerbating factors include pre-existing inequities (e.g., unemployment, financial precarity, and barriers to healthcare access), exclusionary government responses (e.g., relief funds or unemployment benefits), and residential segregation. Mitigating factors include the engagement of CSOs and the implementation of innovative governance strategies such as e-governance and use of teleservices. Recommendations: We recommend increased attention to pre-existing social inequities faced by migrants, inclusive governance strategies, and partnerships between government and CSOs to improve the design and delivery of services to migrants in large urban areas. More research is needed on how urban design can be utilized to mitigate the COVID-19 impacts on migrant communities. Conclusions The factors identified in this systematic review should be considered as part of migrant-inclusive emergency preparedness to address the disproportionate impact of similar public health crises on migrant communities. Key messages Pre-existing inequities, exclusionary governance strategies, and residential segregation led to a disproportionate impact of COVID-19 on migrants living in large urban areas. Mitigators of cities on the COVID-19 impacts among migrants include the engagement of civil society, implementation of innovative governance strategies, and use of teleservices in these settings.


Issue:
In 2015, Italy approved the National Action Plan for Health for and with Roma, Sinti and Travellers (RSC); however, it is still not fully applied at a local level. The INMP (funded by the National Operational Programme for Social Inclusion), implemented the ''Health Project -Promotion of strategies and tools for equity in access to health care for RSC'', aimed to support the implementation of the Plan by Local Health Authorities (ASL).

Description:
The project lasted from March 2019 to December 2021. INMP worked with 7 ASL to design interventions and develop tools to address RSC health needs. The SODA (Strategic Options Development and Analysis) method as a participatory process aimed at identifying strategies and models for the execution of the Plan among relevant stakeholders was used. Moreover, RSC communities' engagement strategies and a communitybased Proximity Public Health (PPS) approach were adopted in designing and developing health promotion interventions.

Results:
INMP performed 38 interviews with ASL health operators highlighting barriers and strategies in the local implementation of the Plan. Tools orienting to social and health services and health education materials for hard-to-reach groups were produced. A training course for 14 RSC facilitators and 5 training courses attended by over 200 NHS operators have been organized. ASL were supported in developing health promotion initiatives, based on the engagement of both local RSC communities and third sector entities.

Lessons:
The project has enabled the ASL to develop local protocols for the implementation of the Action Plan. In line with this capacity-building activity, the project trained both health operators and RSC facilitators fostering the dissemination of the PPS culture in designing and providing care for hard-toreach groups. Given the positive results obtained, INMP is still collaborating with both ASL and the Third Sector on additional activities related to the Project in 2022.

Key messages:
The project has strongly promoted the Proximity Public Health (PPS) approach and the enrollment of RSC communities in designing equity-oriented health interventions.
The SODA methodology and the training of operators have resulted effective in capacitating ASL in the implementation of the Plan.

Background:
Even though large urban areas have been researched in the context of COVID-19, evidence on how COVID-19 impacted migrants -a particularly vulnerable group-in these settings is still limited. Objective: To explore exacerbating and mitigating factors of large urban areas on migrants' vulnerabilities during the COVID-19 pandemic.

Methods:
We conducted a systematic review of peer-reviewed literature published between 2020-2022 and focused on migrants (foreign-born individuals who have not been naturalized in the host country, regardless of immigration status) in urban areas with a population >500.000. After screening 880 studies, 29 studies were included and categorized within the following thematic framework: 1) Underlying structural inequities, 2) governance and economic structure, 3) urban design, and 4) engagement of civil society organizations (CSO).

Results:
Exacerbating factors include pre-existing inequities (e.g., unemployment, financial precarity, and barriers to healthcare access), exclusionary government responses (e.g., relief funds or unemployment benefits), and residential segregation. Mitigating factors include the engagement of CSOs and the implementation of innovative governance strategies such as egovernance and use of teleservices. Recommendations: We recommend increased attention to pre-existing social inequities faced by migrants, inclusive governance strategies, and partnerships between government and CSOs to improve the design and delivery of services to migrants in large urban areas. More research is needed on how urban design can be utilized to mitigate the COVID-19 impacts on migrant communities.

Conclusions:
The factors identified in this systematic review should be considered as part of migrant-inclusive emergency preparedness to address the disproportionate impact of similar public health crises on migrant communities. Key messages: Pre-existing inequities, exclusionary governance strategies, and residential segregation led to a disproportionate impact of COVID-19 on migrants living in large urban areas.
Mitigators of cities on the COVID-19 impacts among migrants include the engagement of civil society, implementation of innovative governance strategies, and use of teleservices in these settings. LGBT+ asylum seekers face multiple challenges in their countries of origin as well as in their host countries. Violence and structural discrimination against this community are common and affect their whole asylum process. Violence and structural discrimination based on sexual orientation and gender identity stress the needs of LGBT+ asylum seekers in particular in regards to reception accommodations. In this study we investigated factors that contribute to the (un)safety of reception accommodations for LGBT+ asylum seekers in Germany. Qualitative semi-structured interviews were conducted with 11 participants from two groups, namely, professionals, and former and current LGBT+ asylum seekers.
Thematic analysis was used to analyze the data and revealed multiple factors influencing the safety of LGBT+ asylum seekers in accommodations. These were clustered according to the used frameworks in the categories individual level, physical and social environment, and policies. The factors for (un) safety included amongst others interpersonal violence based on sexual orientation and gender identity, gender-neutral sanitary areas or lockable rooms, community support, and policies that govern where asylum seekers are accommodated, and which protection measures are set up in accommodations. Applying an intersectional lens, transgender asylum seekers were described as more vulnerable than other LGBT+ individuals. The analysis concluded that binding policies are necessary to guarantee safer accommodations for LGBT+ asylum seekers in Germany. Besides, the social cisheteronormative structures that manifest in discrimination of LGBT+ asylum seekers must be structurally deconstructed by, among others, training staff on LGBT+ needs and increase inclusivity among the asylum seeker community and in the host country.

Key messages:
In Germany, the European country with the highest number of refugees, LGBT+ asylum seekers face many challenges related to their sexual orientation and gender identity. Several factors interplay in the (un)safety of accommodations for LGBT+ asylum seekers.

Background:
Wales is working toward being a Nation of Sanctuary for asylum-seekers and refugees and has resettled between 6,000 and 10,000 refugees since 2001. Uprooted social support networks during the period of asylum-seeking process predispose this population to poverty. The aim of this research was to explore the role of social support among asylum-seekers and refugees in alleviating poverty and its adverse impact on their health and wellbeing. Understanding the importance of social support in promoting the health and wellbeing of asylum-seekers and refugees is a critical factor for informing public health interventions and policies to improve outcomes for tackling poverty among this population in Wales.

Methods:
A qualitative research method, based on social support framework, was adopted. Semi-structured interviews were utilised to collect data from a purposive sample of 8 participants. All the participants were recruited through a refugee support organisation in Cardiff, Wales and were interviewed in the community hub of this organisation. The interviews were digitally recorded, transcribed and analysed using Interpretative Phenomenological Analysis (IPA).

Results:
Results show two formal (government, charities) and three informal (family, friends, and peers) sources of social support as the potential pathways that alleviate the impact of poverty on the health and wellbeing of asylum-seekers and refugees. These sources provide access to language courses, education, employment, housing, food, and sense of belonging in the new communities of resettlement.

Conclusions:
Enhancing access to formal and informal sources of social support is of vital importance to tackling the pernicious impact of poverty on the health and wellbeing of asylumseekers and refugees. Providing social support for this population should be given uttermost consideration for public health interventions and policy decisions in an effort to protect and promote their health and wellbeing. Key messages: Public health interventions and policies should consider access to social support resources by asylum-seekers and refugees. Access to, and quality of, social support resources will alleviate the impact of poverty and improve the health and wellbeing of asylum-seekers and refugees in the host country.

Background:
Migrants who reach host countries irregularly are often perceived as increasing the COVID-19 burden. Italy is a transit and destination country for migrants who cross the Central Mediterranean route. During the pandemic, all migrants who disembarked on the Italian shores have been COVID-19 tested and quarantined. To investigate the incidence of SARS-CoV-2 infection in this population, the INMP, together with the Italian Ministry of the Interior, set a specific information flow collecting data about the infection and possible outcomes.

Methods:
The observation period was from January 2021 to January 2022. COVID-19 tests used were molecular and antigenic. Positive cases detected both at the arrival and during the quarantine period, have been registered on an ad hoc INMP online platform. Migrants' SARS-CoV-2 incidence rate (per 1,000) -with 95% CI -was therefore calculated. The Incidence Ratio (IR) was used to compare the migrants' incidence rate with that of the resident population in Italy, in the same period and corresponding age group.